After two years in existence, the Pioneer Accountable Care Organization (ACO) program has saved the Medicare program $384 million in total, or $300 per Medicare beneficiary per year. Participating providers saved Medicare $279.7 million in 2012 and $104.5 million in 2013. That amount of savings was announced on the website of the Department of Health and Human Services (HHS), and came via an independent evaluation report released May 4 by HHS. What’s more, as the announcement noted, the independent Office of the Actuary in the Centers for Medicare and Medicaid Services (CMS) has certified that the Pioneer ACO program is model “is the first to meet expansion to a larger population of Medicare beneficiaries.”

According to the announcement, “The independent evaluation report for CMS found that the Pioneer Accountable Care Organization (ACO) Model generated over $384 million in savings to Medicare over its first two years – an average of approximately $300 per participating beneficiary per year – while continuing to deliver high-quality patient care. The Actuary’s certification that expansion of Pioneer ACOs would reduce net Medicare spending, coupled with Secretary Sylvia Mathews Burwell’s determination that expansion would maintain or improve patient care without limiting coverage or benefits, means that HHS will consider ways to scale the Pioneer ACO Model into other Medicare programs.”

Reacting to the development, HHS Secretary Sylvia Mathews Burwell was quoted in the online announcement as saying, “This is a crucial milestone in our efforts to build a health care system that delivers better care, spends our health care dollars more wisely, and results in healthier people. The Affordable Care Act gave us powerful new tools to test better ways to improve patient care and keep communities healthier. The Pioneer ACO Model has demonstrated that patients can get high quality and coordinated care at the right time, and we can generate savings for Medicare and the health care system at large.”

The Pioneer ACO Model, one of the first payment models launched by CMS, gives experienced health care organizations accountability for quality and cost outcomes for their Medicare patients. Doctors and hospitals who form Pioneer ACOs can share in savings generated for Medicare if they work to coordinate patient care, keep patients healthy and meet certain quality performance standards, or they may be required to pay a share of any losses generated.

Currently, more than 600,000 Medicare beneficiaries are assigned to Pioneer ACO organizations.

The announcement touted the fact that Medicare beneficiaries enrolled in Pioneer ACOs, on average, “report more timely care and better communication with their providers; use inpatient hospital services less and have fewer tests and procedures; have more follow-up visits from their providers after hospital discharge.” The announcement also noted that the Pioneer ACO program’s evolution harmonizes with broader federal efforts, including with Secretary Burwell’s goal of tying 30 percent of Medicare payments to quality and value through alternative payment models by 2016 and 50 percent to such models by 2018.

Reacting to Monday’s news, the Charlotte-based Premier Inc. released a statement, attributed to Blair Childs, senior vice president for public policy for the nationwide health alliance. “Today’s announcement proves that innovative care delivery models such as the Pioneer ACO program are effective at generating cost savings, while simultaneously improving quality and beneficiary satisfaction with care,” Childs said. “For more than a decade, members of the Premier alliance have been national leaders implementing payment and delivery reforms that improve quality while safely reducing costs.”

Still, Premier’s Childs said in the statement that, “While we support the desire to expand the Pioneer ACO program through track 3, as described in the Medicare Shared Savings Program (MSSP) proposed rule, we believe important changes need to be made, including:

Strengthen the assignment process by allowing Medicare beneficiaries to attest to participation in ACOs;

Establish a more appropriate balance between risk and reward, including higher shared savings for high-quality providers and a period where risk can be phased in over time;

Modify the current benchmark methodology to mitigate the impact on ACOs that lower expenses and achieve savings, and to allow ACOs to decide how to best account for regional and local cost trends;

Employ a risk-adjustment methodology that truly takes into account an individual beneficiary’s acuity;

The American Academy of Family Physicians (AAFP) has sent a letter to Centers for Medicare & Medicaid Services (CMS) acting administrator Andy Slavitt, expressing concerns with meaningful use audits.

Specifically, the letter states that “auditors are causing undue hardship for family physicians with unreasonable and burdensome documentation requests...” This is despite the fact that many family physicians have implemented and use electronic health records (EHRs) in the full spirit of the meaningful use program, the letter attests. “They therefore have a reasonable expectation that the meaningful use financial subsidy would help offset the implementation costs and associated initial decrease in practice productivity.”

The letter, written by AAFP board chair Reid B. Blackwelder, M.D., says that when auditors demand that family physician practices produce documentation years after the fact, unreasonable burden is created. “This is especially burdensome for family physicians who have made changes to their practice or have been acquired by a larger healthcare organization,” the letter says.

Another concern, according to AAFP, stems from employed physician situations, since many employment contracts include a clause stating all Medicare payments are turned over to the practice. “This creates an issue when the practice received the meaningful use subsidy, but years later, the individual physician is held responsible for repaying the payment after a failed audit.”

The letter also calls into question the effectiveness, responsiveness, and expertise of the auditors, as well as saying that the program’s “all or nothing” nature means that missing one document may lead to a failed audit and a repayment of the full subsidy payment. In reality, says AAFP, the audit program does not appear to take into consideration the high likelihood that a failed audit can be caused simply by missing documentation rather than by not achieving the meaningful use requirements.

AAFP calls for increased transparency from the federal government regarding audit statistics including the number of audits and the failure rate. “It would be helpful to have a report on what documentation was missing from failed audits. That would enable eligible professionals to have a better understanding over the type and granularity of documentation required,” the letter says.

With the vast amounts of data collected in the healthcare industry, providers, vendors, and other stakeholders are putting more focus into developing health information exchange (HIE) and greater EHR interoperability. The Office of the National Coordinator for Health IT (ONC) released a report to Congress – Update on the Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information – to offer policy guidance on the best ways for optimizing health IT systems and supporting HIEs.

Ever since the federal government passed the Health Information Technology for Economic and Clinical Health (HITECH) Act, the number of hospitals and physician practices adopting EHR systems has grown substantially. Currently, more than half of hospitals have at least a basic EHR system in place while, in 2013, 48 percent of physicians had EHRs at their practice.

Additionally, eligible professionals and eligible hospitals across the country are participating in the Medicare and Medicaid EHR Incentive Programs. While there has been significant progress in implementing health IT, there are still barriers that are halting widespread health information exchange across healthcare organizations and vendor products.

For example, if an individual from Maine takes a vacation in Florida and experiences a patient encounter, their primary care provider from Maine would likely not be informed nor would be able to access the patient’s emergency care data.

The report states that some of the common barriers to EHR adoption and thereby challenges for expanding health information exchange include the cost of purchasing a system, loss of productivity, training difficulties, the costs of annual maintenance, and obstacles related to finding an EHR system that supports practice needs. Nonetheless, in 2013, eight in ten physicians were using an EHR system or planning to adopt one, according to an ONC data brief.

ONC explains in its report that some of the reasons health information exchange is lacking is due to inconsistent structure, format, and even medical vocabulary used across different EHR systems and vendor products. ONC outlines key actions the Department of Health and Human Services (HHS) will need to take to improve nationwide EHR interoperability. These actions include:

Creating new standards that are integral to the development of a connected healthcare system

Requiring more staff in the health IT workforce to support the implementation of electronic records

Improving the sharing of data among providers and public health agencies

Collaborating, advising, and sharing studies with states, communities, and providers to stimulate IT solutions in the healthcare field

Driving patient engagement with their health information

ONC hopes that Stage 2 Meaningful Use requirements will also catalyze a widespread data exchange network within the healthcare sector. By using these five strategies, HHS plans to further advance health information exchange and invest in health IT usability throughout the nation.

Over the last several years, a multitude of providers have found meaningful use requirements too complex and advanced to reach as quickly as the Centers for Medicare & Medicaid Services (CMS) mandates. Specifically, the healthcare industry is calling for more EHR flexibility when integrating these systems.

Due to the large volume of concerns from stakeholders and healthcare providers, CMS did move forward with revising some aspects of the meaningful use requirements. For example, instead of reporting on EHR use in a full calendar year, CMS decided to implement a 90-day reporting period instead.

“We continue to support the long-term goals of the meaningful use program and share the Department of Health and Human Services’ commitment to elevating patient-centered care and improving health outcomes, but greater flexibility is needed to support the providers and make participation less daunting,” American Academy of Family Physicians President Dr. Robert Wergin said in a public statement.

Along with concerns over meaningful use requirements, the lack of sharing capabilities among EHR systems is also causing providers to worry. The lack of EHR flexibility and interoperability is a significant concern, which the Office of the National Coordinator for Health IT (ONC) recently addressed by releasing a 10-year roadmap.

While approximately half of providers and 59 percent of hospitals have implemented EHR technology, not nearly as many physicians have the EHR flexibility necessary to communicate with doctors at other establishments. The Department of Health and Human Services (HHS) reported that, in 2013, only 14 percent of physicians electronically shared data with ambulatory care providers or hospitals that were outside of their facility.

Additionally, that same year only 10 percent of hospitals were offering their patients online access to view, download, and distribute their personal health records based on their hospital stay.

On March 18, the American Hospital Association (AHA) advised Congress to allow providers more EHR flexibility when implementing these systems. With the ICD-10 transition taking place on October 1, providers will need more secure and flexible products when adopting the new coding set.

Additionally, the recent release of the Stage 3 Meaningful Use proposed rule sets 2018 as the anticipated year for meeting the requirements. This may be difficult to achieve for providers that are still struggling to attain Stage 2 Meaningful Use regulations.

In a statement by AHA to the Senate Committee on Health, Education, Labor and Pensions, the organization commented on how health IT tools do not support a high level of health information sharing. AHA asks for the development of policy that supports EHR flexibility and the designing of systems to securely adapt to the ICD-10 coding set.

AHA also highlights the importance of delivering health IT products that promote patient safety and quality improvements. The various EHR issues including data exchange concerns will need to be addressed by the federal government over the coming months, as the ICD-10 transition is currently set to take place on October 1, 2015.

While ICD-10 acknowledgment testing is available any day of the year up until October 1, 2015, CMS is taking the first week in March to host another dedicated opportunity for providers. The testing weeks serve as way to gather data about the way providers send their sample ICD-10 claims to Medicare and allow providers to ensure that their claims can be accepted by the adjudication system without any technical glitches.

Those organizations that have not participated in previous testing weeks are encouraged to join in during the next chance on March 2 through 6, or the final scheduled occasion at the beginning of June.

In order to successfully submit claims for ICD-10 acknowledgement testing, direct-submit healthcare organizations, including providers and clearinghouses, will need to keep the following questions, tips and, requirements in mind.

What is ICD-10 acknowledgement testing?

Acknowledgement testing is the most basic form of assurance that a claim can be accepted by a Medicare Administrative Contractor (MAC) for later adjudication. It should not be confused with end-to-end testing, in which a claim is processed through all Medicare system edits in order to produce electronic remittance advice (ERA). Acknowledgement testing simply provides a yes or no answer to the question of whether or not the sample claim can be accepted.

Providers are encouraged to use ICD-10 acknowledgement testing as a basic way to ensure that they are on the right track with their ICD-10 preparation.

How do I participate?

Information about acknowledgement testing will be provided on your local MAC website or by your clearinghouse. Any provider that submits electronic Medicare fee-for-service claims is eligible for participation. There is no registration required. For more information on eligibility, click here.

ICD-10 acknowledgement testing does not test initial connectivity to the MAC system, nor does it ensure that your internal systems are capable of producing, accepting, storing, or transmitting codes. Internal preparations for the generation and transmission of ICD-10 codes should already be completed before MAC testing.

How do I prepare my sample claims for submission?

Ensure that you have enough claims coded in ICD-10 to represent your typical submissions spectrum. CMS reminds providers that claims must have the “T” in the ISA15 field to indicate the file is a test file. Use a valid submitter ID, national provider identifier (NPI), and Provider Transaction Access Numbers (PTAN) combinations. Claims that contain invalid identifiers will be rejected.

Be sure that the claims do not include future dates of service. All claims must be dated before March 1, 2015 in order to be processed. Claims must also have an ICD-10 companion qualifier code or they will be rejected.

Providers may engage in “negative testing” by submitting purposely erroneous claims in order to confirm that the MACs will catch defects or incorrect information.

What information will I receive from my MAC?

Test claims will be assigned a 277CA or 999 acknowledgement as confirmation that the claim was accepted or rejected by the system. The test will not confirm that the claim would be paid under ICD-10, nor will testers receive any remittance advice. The MACs and the Durable Medical Equipment (DME) MAC Common Electronic Data Interchange (CEDI) will have extra staff available to take calls from providers who have questions about the process or their results.

Providers will need to engage in full end-to-end testing with their payers if they wish to receive information about their coding accuracy or payment rates. While CMS has scheduled end-to-end testing for April 2015, participating providers have already been selected. Providers are still encouraged to engage in end-to-end testing with their private payers as soon as possible.

What do I do next?

During prior acknowledgement testing, CMS has released basic data on acceptance rates several weeks after the dedicated testing period. But providers participating in the opportunity do not need to wait until then to take action based on their own results. With a mere seven months until October 1, 2015, organizations that experienced unexpected denials from acknowledgement testing should work with their ICD-10 preparation teams or consultants to resolve internal or coding errors quickly.

Healthcare organizations should also make sure that they are coordinating with their major payers to conduct additional, more robust testing of ICD-10 claims. Providers should continue to utilize clinical documentation improvement programs, revenue cycle contingency planning, and coder training and education during the last few months of preparation in order to combat potential negative impacts from the new codes.

While this week marks the end of one and beginning of another year, those in the healthcare industry should take note of all that transpired in the previous year to avoid similar setbacks in 2015. This is especially true for matters scheduled to have been addressed over the last 12 months.

ICD-10 delays, meaningful use changes, health IT vendor competition, and EHR implementation gaffes. Based on the interest of our readers, those were the most popular topics of 2014 on EHRIntelligence.com.

ICD-10 transition delay one more year

More than any other topic on our news site, ICD-10 garners the greatest amount of our readership’s attention and given its high stakes, it makes sense. This past October was supposed to usher in a new era of clinical coding — the move from ICD-9 to ICD-10 — and put the United States on par with other leading nations in terms of healthcare documentation.

What the delay meant to providers depended on where they practices. Larger healthcare organizations reported high levels of ICD-10 readiness while some smaller physician groups and practices were completely unsure where they stood. No matter their view of the most recent ICD-10 delay, most are committed to removing ICD-10 implementation pain points to be ICD-10 ready by Oct. 1, 2015.

Early hints of changes to meaningful use reporting in 2014 emerged as early as February when the Centers for Medicare & Medicaid Services (CMS) introduce a new meaningful use hardship exception dealing with a lack of available CEHRT.

In September, the federal agency finalized a rule intended to give providers greater flexibility in meeting meaningful use requirements in 2014 — known as the flexibility rule. However, this did not turn out to be CMS’s final move.

The flexibility rule was followed by the reopening of the meaningful use hardship exception application submission period for both EPs and EHs and the extension of the 2014 meaningful use attestation period for EHs and critical access hospitals through the end of the year.

Despite their intentions, neither has put to rest repeated calls for 2015 meaningful use reporting requirement changes by industry stakeholders.

Heading to a showdown

Prognosticators in health information technology (IT) have foreseen consolidation in the marketplace over the next few years. But it is unlikely that they saw things playing out as they did in 2014.

While the growth of both Cerner and Epic continues to loom large over the industry, they still have to contend with numerous other players in the ambulatory care space, especially given Epic’s recent loss to athenahealth as the top overall software vendor over the past year.

Expect more to come.

Squeaky wheel gets the grease

When EHR implementations go well, those involved in the process are more than willing to share details of their experiences. When they don’t, it is like pulling teeth.

If 2014 was a busy year, then 2015 is only likely to be busier. Stay with us as we continue our coverage of meaningful use, EHR and ICD-10 implementation, and anything else health IT-related that comes our way.

On April 10, 2015, the Centers for Medicare & Medicaid Services issued a new proposed rule for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs to align Stage 1 and Stage 2 objectives and measures with the long-term proposals for Stage 3, to build progress toward program milestones, to reduce complexity, and to simplify providers’ reporting. These modifications would allow providers to focus more closely on the advanced use of certified EHR technology to support health information exchange and quality improvement.

Better Care, Smarter Spending and Healthier People The proposed rule is just one part of a larger effort across HHS to deliver better care, spend health dollars more wisely, and have healthier people and communities by working in three core areas: improving the way providers are paid, improving the way care is delivered, and improving the way information is shared to support transparency for consumers, health care providers, and researchers and to strengthen decision-making.

Vision for the Future

The proposed rule issued today is a critical step forward in helping to support the long-term goals of delivery system reform; especially those goals of a nationwide interoperable learning health system and patient-centered care. CMS is also simplifying the structure and reducing the reporting requirements for providers participating in the program by removing measures which have become duplicative, redundant, and reached wide-spread adoption (i.e., are “topped out”). This will allow providers to refocus on the advanced use objectives and measures. These advanced measures are at the core of health IT supported health care which drives toward improving the way electronic health information is shared among providers and with their patients, enhancing the ability to measure quality and set improvement goals, and ultimately improving the way health care is delivered and experienced.

Simplifying and Streamlining

The proposed rule would streamline reporting requirements. To accomplish these goals, the NPRM proposes:

Reducing the overall number of objectives to focus on advanced use of EHRs;

Removing measures that have become redundant, duplicative or have reached wide-spread adoption;

Realigning the reporting period beginning in 2015, so hospitals would participate on the calendar year instead of the fiscal year; and

Allowing a 90 day reporting period in 2015 to accommodate the implementation of these proposed changes in 2015.

Supporting Interoperability and the Adoption of Electronic Health Records

The EHR Incentive Programs support the adoption and meaningful use of certified EHR technology to allow providers and patients to exchange and access health information electronically and support interoperability broadly. The program supports interoperability by requiring the capture of data in structured formats as well as the exchange of data in standardized form as well as the sharing of this data electronically with other providers and with patients.

The proposed rule would reduce required reporting, allowing providers to focus on objectives which support advanced use of EHR technology and quality improvement, including health information exchange.

Improving Outcomes for Patients

The rule would support improved outcomes and measurement of those outcomes. By proposing to simplify the reporting requirements, the proposed rule would allow providers to focus on objectives that support advanced use of EHR technology, including quality measurement and quality improvement. The rule supports providers leveraging their resources and health IT to coordinate care for patients, to provide patients with access to their health information, and to support data collection in a format that can be shared across multiple health care organizations.

Program Registration and Participation Milestones

As of March 1, 2015, more than 525,000 providers have registered to participate in the Medicare and Medicaid EHR Incentive Programs. In addition, more than 438, 000 eligible professionals, eligible hospitals, and CAHs have received an EHR incentive payment. As of the end of 2014, 95% of eligible hospitals and CAHs, and more than 62% of eligible professionals have successfully demonstrated meaningful use of certified EHR technology.

It’s been a very busy last few weeks in health IT. While everyone is doing their annual prep for the upcoming Healthcare Information and Management Systems Society (HIMSS) conference, held this year in Chicago in two weeks, a few major policy developments have hit the industry and have the potential to bring massive change to the healthcare landscape.

One of these developments is the proposed legislation to repeal Medicare’s Sustainable Growth Rate Formula (SGR) for physician payment, and institute a 0.5-percent payment update for the next five years for physicians, under Medicare. This bill has been passed in the House of Representatives, and is expected to pass in the Senate in two weeks, according to HCI sources with Congressional ties. While it was reported that there was no language in the bill that would further push back the transition to ICD-10—currently set for Oct.1, 2015—it would be foolish to ever count such a thing out, after past developments have proved that no matter what you might think, there could be high-level people behind another delay.

However, in his Washington Debrief this week, Jeff Smith, vice president of public policy at the College of Healthcare Information Management Executives (CHIME) noted that, “Despite the introduction of an amendment to delay the new coding set to 2016 by freshman Representative Gary Palmer (R-MS-04) it was not allowed to be included in the bill by House leadership.” Indeed, in January, Palmer was part of a group of congressional members who sent a letter to Alabama's Congressional Delegation urging to delay implementation of ICD-10 until October 2017, if not get rid of it completely until ICD-11 comes around.

The letter stated various reasons why a delay was necessary, mainly the increased granularity with codes and the extra cost for healthcare organizations. “While spending more time with patients is what patients and physicians want, under ICD-10 we will instead spend more hours in front of a computer screen scanning 68,000 medical codes looking for the right one,” the letter states. It continues, “The transition to ICD-10 is expected to cost more than $1.64 billion over 15 years, with more than 40 percent of that expense coming from the cost of upgrading information technology systems for different participants including the government, insurance companies, physicians and hospitals.”

While I won’t argue the specific points of cost and physician training, I will disagree with Palmer on his overall take. Simply put, the industry cannot go through the burden of another delay; its effects would be rippling. There has been a great deal of money spent on ICD-10 already. How do vendors, hospitals, physician groups, and others recoup the loss of money spent getting ready if yet another delay occurs? A delay until 2017 is just the wrong move—as our Senior Editor Gabe Perna reported last month, on an ICD-10 hearing held by the House of Representatives’ Energy and Commerce Committee’s Subcommittee on Health, one of the panel members said it’s time to move forward or pull the plug. And to be honest, it’s too late to pull the plug. There has been too much invested already.

Also, regarding the boost in medical codes, while naysayers point to the increased granularity involved with that, it’s likely that providers won’t have to worry about all of them. This is according to Fletcher Lance, managing director and national healthcare leader of the Nashville, Tenn.-based North Highland, a global consulting firm, who recently told me that the firm’s Codes That Matter approach prioritizes ICD-10 implementation activities by identifying those codes that are tied to the largest revenue streams at a given healthcare organization.

To find the codes that matter, North Highland assesses multiple factors that contribute to the complexity and potential impact of the ICD-10 transition on physician and clinician productivity and organization revenues. As such, Lance says, “We find that, of the 68,000 codes that you’ll see in the hospital setting, maybe 300-500 codes matter, and often even less than that,” he says. “Not all codes are created equal; we can and have predicted which ones matter.”

This is not to say that the extra training and education isn’t necessary, but that it might not be as drastic as people such as Palmer are saying. It’s also not to say that ICD-10 doesn’t come without concerns. Earlier this month, nearly 100 physician groups representing state and specialty medical societies have written a letter to the Centers for Medicare & Medicaid Services (CMS) regarding said concerns, specifically about a lack of industry-wide, thorough end-to-end testing. Certainly, ICD-10 is not without problems or challenges, but another delay or pulling the plug is not the answer at this point of time.

The time has come to finally close the door on any talk of more delays, and see ICD-10 through to its completion. The transition needs to be done both correctly and on time, or the same cycle of ambiguity will only continue. At this point it doesn’t even matter what side you are on when it comes to the transition—after all the work that has already been done, it’s time to move forward. Thankfully, it looks like the lack of an amendment in the SGR repeal legislation will allow us to do just that.

As we know many payers are implementing various approaches to pay-for-performance reimbursement or value-based reimbursement programs. Medicare has announced significant goals in modifying payment models; rolling out value-based payment modifiers (VBPM) this year. Patient care activity in 2015 will impact every Medicare payment in 2017. Physician groups of 100 or more will have payments affected this year, groups of 10 or more in 2016, and all groups in 2017. Medicare will determine the amount of payment incentive or adjustment based on the information noted below. The range is from - 4 percent to + 4 percent of Medicare payments.

Below are some thoughts on how you can respond to VBPMs and optimize the care provided patients and maintain or gain financial viability.

1. Continue to participate in PQRS which is the basis for the Medicare Value-Based Payment Modifier program. Understand how your profile fits within the six domains (check meaningful use): clinical process/effectiveness; patient and family engagement; population/public health; patient safety; care coordination; and efficient use of healthcare resources.

2. Access your practice Quality and Resource Use Report, QRUR, by obtaining an IACS number from CMS. This report was published by CMS last fall and compares your practice to peers on both quality and cost measures. This can be downloaded in both PDF and excel formats. It's complex but worth spending time on to both understand and identify your practice profile.

c. Medicare Spend Per Beneficiary, MSPB, for three days prior to and 30 days post discharge

d. Total Medicare Allowable per applicable CPT code

4. Report monthly on what is occurring.

a. Your practice will not know the Medicare ranking until the end of period.

b. Rankings are determined by the eligible provider (EP) who has a "plurality" of primary-care codes assigned and the Medicare allowable charge amount assigned. Primary-care providers will be considered first, but any specialist may qualify.

c. A minimum of 20 episodes per measure (see quality above) hence the need to monitor your practice. If insufficient numbers are there, you may not see either the incentive or adjustment.

5. Regular review and reporting will help lead the practice toward a more "quality" impact and focus. Whenall staff,not just providers, work together, the cumbersome nature of reporting will become easier and part of everyday practice life — since in many cases the impact is not significant this year. It will however become more impactful in the years to come, as not only VBPM programs come into play, but overall payment model reforms are implemented. There will be an eventual culture change!

Long term outcomes for practices should be improved patient care, compliance with the new paradigm, and an improved financial picture. How you approach it now may determine the long-term success and viability of your practice in the future.

Over the past two years, there has been a lot of talk about a big EHR switching trend. Some of this has been because of Meaningful Use, and some of it has been because of market changes. There are simply more options today if you are unhappy with your current EHR.

What sometimes gets left out are the other opportunities created by using an EHR. Some of these are new revenue sources that might be impossible or very hard to access without one. Here are a few examples, but certainly not the only ones.

Medicare Programs

There are some new codes that have come out in the last two years for services that are revenue generators, but you really do need an EHR to manage them. The first is transitional care management (TCM). While TCM doesn’t require you to use an EHR, the complexity of it makes it hard to do without one. The ability to easily put in your notes and set reminders for needed follow up makes managing TCM much easier. With reimbursement ranging anywhere from about $100 to over $200 per patient, this can be a great opportunity for providers who see many patients who need post hospitalization follow ups.

The other Medicare program is newer and does require the use of a certified EHR. It is the Chronic Care Management (CCM) code that came out this year. The reimbursement is about $42 per patient and can be billed once a month. The requirement is that the patient has two or more chronic conditions that are expected to last at least 12 months or until the patient’s death. Clinical staff must spend at least 20 minutes performing CCM services for the patient each month that the code it billed. The services are non-face-to-face and direct supervision is not required, which means that nursing staff or non-physician practitioners can render CCM even if the physician is not in the office. Again, if your practice sees a lot of patients with chronic health problems, this can be a great way to add revenue by using nursing or mid-level staff.

Affordable Care Act Opportunities

By now I hope everyone knows that preventive care services are covered with no copays or deductibles. What many providers still aren’t very aware of are the other types of programs that are now covered by insurance that can be great revenue generators. While they don’t require an EHR, this is another area where using an EHR makes running these programs much easier. The two programs that make a lot of sense for primary care providers and specialists who see patients with certain types of qualifying conditions are group visits and weight loss programs.

With group visits, the practice identifies a group of patients who have a similar, chronic condition that requires frequent visits. You can do this using your EHR (it would be tough using paper charts). Some examples include HIV, chronic pain, COPD, and hypertension. Vitals are done individually as patients arrive and then the whole group spends the rest of the 1.5 – 2 hour visit together with the provider. Once a group visit is completed, each patient’s insurance is billed for the appropriate E&M code for their individual situation. The ability to use templates and copy note features in the EHR can make documenting after the group visit much faster and easier than it would be if done by hand.

For patients with certain conditions, a weight loss program may be mostly or fully covered by insurance like preventive care. The great thing about this is that it can be as simple or complex as you are willing to manage. You can do simple nutritional counseling and weigh-ins or go for a fully formed program through a third party that includes food and supplements. Again, using an EHR makes it much easier and faster to manage and track multiple follow up appointments, set reminders, and copy notes and simply update them each time. You can even have a group visit component!

The key to all of these opportunities is that an EHR helps reduce the complexity of managing the requirements and helps insure that you can quickly and easily show accurate, thorough documentation to payers. Without an EHR, these revenue generating programs would simply seem too difficult to manage. In a time when every penny counts, you can’t ignore opportunities like these.

Under the Medicare EHR Incentive Program, healthcare facilities may receive a maximum incentive payments of $44,000 over the course of five sequential years. The payments first started in 2011 and will continue until the end of 2016. Meanwhile, the Medicaid EHR Incentive Program confers a maximum of $63,750 over six years. In order to receive these incentives, eligible professionals and hospitals must prove they are meaningfully using certified EHR technology (CEHRT) in their practices. After first-year entities participated in the program, they could obtain as much as $18,000. In subsequent years, incentive payments were lower, ending with $2,000 by the fifth year for Medicare eligible professionals.

In 2009, Congress passed a ruling within the American Recovery and Reinvestment Act that assigned payment adjustments or penalties to eligible medical professionals and hospitals that did not meet meaningful use requirements of CEHRT under the Medicare EHR incentive program. Eligible providers who do not meet meaningful use will receive one-percent payment reduction in the first year, which will rise in every subsequent year to a maximum of five percent.

Healthcare providers who are eligible only for the Medicaid program will not have the burden of these payment adjustments. For those who serve both Medicare and Medicaid patients, they will be subject to payment adjustments if they fail to meet meaningful use requirements.

The first penalties began on October 1, 2014 for Medicare hospitals. Eligible professionals who did not meet meaningful use requirements received their first payment adjustment after January 1, 2015. Recently, CMS announced that approximately 78,000 eligible professionals are subject to meaningful use penalties of more than $2,000.

“The penalties physicians are facing as a result of the Meaningful Use program undermine the program’s goals and take valuable resources away from physician practices that could be spent investing in better and additional technologies and moving to alternative models of care,” Steven J. Stack, MD, President of the American Medical Association, said in a statement. “The AMA continues to work with the Administration to improve the Meaningful Use program and looks forward to seeing how CMS’ anticipated new rules address these issues this spring.”

Despite the burden of the penalties, CMS does offer exceptions to those truly having difficulty implementing CEHRT and meeting the requirements of meaningful use. Those who are eligible but unable to meet meaningful use requirements due to a significant hardship are allowed to file for a meaningful use hardship exemption by completing an application. Upon approval of the hardship, it is valid for one year only and a subsequent application must be presented the following year. A hardship exemption may not be granted for any longer than five years.

There are also a handful of cases in which entities will not need to submit hardship exemption applications but will automatically be given an exception. These include new providers in their first year of service and professionals of specific PECOS specialties among others.

For those who wish to avoid a payment penalty in subsequent years, the National Library of Medicine offers tools that help providers meet EHR certification conditions and reach meaningful use stipulations.

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